Rethinking Denial Management: How Prevention Outperforms Recovery

Originally aired Wednesday, September 30th 

Coding is now the denial category that decides the margin. Coding related denials rose 26 percent across hospital outpatient and professional settings in 2025, on top of a 126 percent outpatient jump the year before, and they have passed eligibility, registration, and pre-cert as the top category. Payer audit at-risk dollars climbed 30 percent. Medicare Advantage RFI and medical necessity denials rose fivefold. Payers are taking longer to respond and down-coding high weight DRGs and high intensity ED codes automatically, which converts revenue leakage into False Claims Act exposure. Retrospective review cannot close a gap that opens before the claim leaves the building. What works is interrogating 100 percent of charges at code complete, when the fix still costs nothing.

What You Will Learn

• Why coding related denials overtook front-end categories, and which settings are absorbing the damage
• How automated payer down-coding creates compliance risk, not just lost reimbursement
• What governance around autonomous coding actually has to look like to hold up
• How pre-bill interrogation changes DRG accuracy, first pass pay rates, and days in AR
• What is new in eValuator, and how confidence scoring and financial impact prioritize the work

Who Should Watch:

Revenue cycle and revenue integrity leaders, HIM and coding directors, billing compliance leaders, and healthcare finance executives.

What You Will Take Away:

A pre-bill operating model to bring back to the program, grounded in MDaudit benchmark data from 4,500 facilities, along with a practical view of what charge-level accuracy looks like when it happens before submission rather than after.